Fear avoidance and return to work after mild traumatic brain injury

OBJECTIVES

Fear avoidance is associated with symptom persistence after mild traumatic brain injury (mTBI). In this study, we investigated whether fear avoidance was associated with other outcomes such as return to work-related activity (RTW).

MATERIALS AND METHODS

We analyzed associations between fear avoidance and RTW 6-9 months after mTBI, in two merged prospective mTBI cohorts. Adult participants aged 16 or over (n=175), presenting to outpatient services in New Zealand within 3 months of their injury, who were engaged in work-related activity at the time of injury, were included. Participants completed the Fear Avoidance Behavior after Traumatic Brain Injury (FAB-TBI) questionnaire at enrollment and 6 months later. Associations between FAB-TBI scores and RTW outcome were analyzed using multivariate approaches.

RESULTS

Overall, 53% of participants had RTW by 6-9 months after mTBI. While early fear avoidance was weakly associated with RTW, persistent high fear avoidance between study assessments or increasing avoidance with time were associated with greater odds of still being off work 6-9 months after injury.

CONCLUSIONS

Pervasive and increasing avoidance of symptom triggers after mTBI were associated with lower rates of RTW 6-9 months after mTBI. Further research is needed to better understand transition points along the recovery trajectory where fear avoidance behaviors fade or increase after mTBI.

Psychosocial and financial impacts for carers of those with eating disorders in New Zealand

BACKGROUND

Eating disorders (ED) can have profound effects on family members and carers. These impacts can be experienced across multiple domains and may contribute to the maintenance of ED symptoms. In the absence of any New Zealand studies quantifying this, and given country-specific differences in access to care and treatment, this study explores the psychosocial and economic impacts on those caring for someone with an ED in New Zealand.

METHODS

Carers (N = 121) of those who had, or still had, a self-reported ED (82.6% anorexia nervosa) completed an online survey open between December 2016 and October 2020, adapted to the New Zealand context. Questions addressed ED recency and recovery status of the individual cared for, treatment access, and the financial and psychosocial impact on the carer. Data analysis included descriptive statistics, with financial cost data converted to the equivalent of 2020 New Zealand dollars.

RESULTS

Most (88.6%) recruited carers reported still caring for someone with ED symptoms of varying severity. A majority reported difficulty accessing treatment for the person they cared for, with a sizable minority (45%) paying for private treatment, despite few having private insurance. Carer losses typically included reduced income and productivity, travel costs, and other miscellaneous costs. Carers reported significant psychosocial impacts across a range of dimensions including family life, interpersonal relationships, and their own personal well-being.

CONCLUSIONS

Carers in New Zealand report impacts which are far reaching and longstanding, covering their own personal and interpersonal well-being and that of those around them. While most of those they care for get access to public (free) treatment at some time or another, the wider financial and economic impacts on carers are significant, and likely to take years to recoup. Though not unique to EDs, interventions and supports for carers are much needed in New Zealand, alongside more comprehensive research methodology to further determine positive and other impacts of EDs over the long course of the caregiving role.

HIGHLIGHTS

A majority reported difficulty accessing treatment for the person they cared for 45% paid for private treatment, despite few having private insurance Carers reported reduced income and productivity, travel costs, and other costs. Carers reported significant psychosocial impacts on family life, interpersonal relationships, and their own personal well-being. Carers provide a pivotal role in supporting treatment and recovery in their family member with the These findings will be relevant for funders and service providers in developing further approaches to address barriers and gaps in service provision to reduce impacts on carers, and as a result, those with eating disorders.

Fifteen Years On: What Patterns Continue to Emerge from New Zealand's Health Practitioners Disciplinary Tribunal?

Disciplinary tribunals are deserving of review, in the interests of fairness, transparency and educational value for key stakeholders. New Zealand's Health Practitioners Disciplinary Tribunal (HPDT) determines whether registered health practitioners have engaged in misconduct that warrants discipline. The current study considers patterns regarding HPDT hearing processes and outcomes (2004-2020) (420 decisions), expanding knowledge from a previous analysis of HPDT decisions (2004-2014). The findings suggest that the HPDT has largely upheld its goal of consistency. However, shifts over time have included a reduced rate of appeals, and changing patterns for both the grounds for discipline and penalties applied. Differences in HPDT processes and penalties between medical practitioners, nurses and pharmacists were largely accounted for by the factors of practitioner attendance and legal representation at the hearing. This study contributes to understanding who transgresses, how they transgress and the penalties imposed. Such insights may be applied preventively for the benefit of all stakeholders.

Commentary on disordered eating symptoms and bariatric/metabolic surgery

OBJECTIVE

This article presents an argument for the rethinking of concerns around bariatric/metabolic surgery in people with disordered eating.

CONCLUSION

Practice has usually been cautious but disordered eating and eating disorders should not be a contraindication other than exceptional cases. Further research directions are suggested.

Exploring how therapeutic horse riding improves health outcomes using a realist framework

Introduction

Evaluating how therapeutic horse riding improves health for children experiencing disability is made complex by a lack of clarity around mechanisms of treatment effect. This research develops an explanatory theory outlining how health outcomes may be optimised, by exploring what works for which riders, under what conditions and how.

Method

Within a realist research framework, we undertook three phases of study using a mix of qualitative and quantitative data collection and analysis approaches. Findings were then integrated into an overall evaluative account.

Results

Riders with a range of impairments ( n = 32; aged 5 to 17 years), caregivers ( n = 29) and therapeutic horse riding providers ( n = 16) participated. Three key mechanisms of intervention effect are proposed: (1) therapeutic horse riding facilitates development of a rider’s self-concept through opportunities for accessible, meaningful participation; (2) the context in which therapeutic horse riding is provided promotes a focus on riders’ capacities and strengths and (3) therapeutic horse riding provides opportunities for a broad range of learning experiences.

Conclusion

Therapeutic horse riding provides opportunities for meaningful occupational participation for children experiencing disability. Ensuring that the physical and ideological context in which therapeutic horse riding is provided focuses on a rider’s capacities and strengths will enhance self-concept development and participation outcomes.

Consensual Sexual Relationships between Health Practitioners and Their Patients: An Analysis of Disciplinary Cases from New Zealand

Consensual sexual relationship between health practitioners and their patient are considered one of the most serious breaches of professional boundaries. Prevalence rates are difficult to establish since underreporting may occur, yet media attention may conflate the perception of prevalence. In this study we first reviewed the literature for risk factors for health practitioners and patients, professional standards, and responses of disciplinary bodies. Following this, we quantitatively summarised case characteristics and disciplinary outcomes from a 14-year cohort of New Zealand's Health Practitioners Disciplinary Tribunal proceedings. From the 26 cases identified, four themes were discussed in detail and illustrated with cases. These include: female practitioners working in correctional settings; zero tolerance but no registration repercussions; patient vulnerabilities when help-seeking for mental health issues; and the use of rehabilitative penalties. Despite the difficulties in conducting research on sexual boundary violations, this raises awareness, encourages proactive reporting, and inspires constructive strategies.

Evaluating the effectiveness of therapeutic horse riding for children and young people experiencing disability: a single-case experimental design study

Purpose: Therapeutic horse riding aims to improve the health of children and young people experiencing disability; however, its benefits across a range of health domains, particularly the impact on participation outcomes, are not well known. This research evaluated to what extent there was a change in riders balance, functional performance, social responsiveness, quality of life and participation outcomes as a result of therapeutic horse riding.Methods: A multiple-baseline across participants (n = 12) single-case experimental design, with randomly allocated baseline phase lengths, quantitatively evaluated how riders responded to a 20-week intervention.Results: Social participation outcomes measured using the Canadian Occupational Performance Measure demonstrated the most consistent positive between-phase differences (performance ES = 1.20, 95% CI [0.82, 1.63]; satisfaction ES = 1.11, 95% CI [0.73, 1.55]). A causal relationship was seen in three riders, but improvements only reached clinical significance for two riders when accounting for phase data trends. No significant outcome patterns were found comparing riders with principally physical impairments to those with principally psychosocial impairments.Conclusions: Being involved in therapeutic horse riding may improve rider's social participation in home, school and community settings. We postulate that rider self-concept development may be a mechanism of treatment effect leading to participation-level changes.Implications for rehabilitationSocial participation was the health outcome demonstrating the most consistent change following therapeutic horse riding, regardless of rider impairment.Therapeutic horse riding can improve social participation in settings beyond the riding arena.Greater intervention tailoring based on rider responses may enhance therapeutic horse riding intervention effects.

Wrestling with uncertainty after mild traumatic brain injury: a mixed methods study

Purpose: Our objective was to explore the intersection between mild traumatic brain injury (MTBI) recovery experiences and injury understandings, using both quantitative and qualitative methods.Materials and Methods: The quantitative component was a descriptive case-control study comparing participants (n = 76) who had recovered or not recovered after an MTBI, across demographic and psychological variables. A subset of participants (n = 10) participated in a semi-structured interview to explore experiences of recovery in more detail. We followed threads across the datasets to integrate findings from component methods.Results: The quantitative analyses revealed differences between the two groups in terms of injury recovery understandings and expectations. The qualitative analyses suggested that achieving consistency across information sources was important. By tracing threads back and forth between the component datasets, we identified a super-ordinate meta-theme that captured participants' experiences of wrestling with uncertainty about their recovery and the impacts in terms of heightened anxiety, confusion, and feelings of invalidation.Conclusion: The effectiveness of psychoeducation and reassurance after MTBI may be optimized when content is tailored to the individual. Clinicians are urged to attend both to the subjective interpretations patients make of information gained from formal and informal, internal and external sources, and where information across these sources conflicts and creates uncertainty.Implications for rehabilitationEffectiveness of psychoeducation and reassurance after injury may be optimized when content is tailored to the individual rather than being generic.Effectiveness of such interventions may also be optimized by understanding the subjective interpretations individuals make of injury knowledge gleaned from formal and informal, internal and external sources.Conflicting information from such multiple sources may create uncertainty with associated increased distress as an individual negotiates their recovery from injury. Attending to this uncertainty may be a helpful target for treatment.

Outcomes of Notifications against Psychologists in the New Zealand Health Regulation Context 2004-2015

Research focusing on disciplined health practitioners is growing though exploring lower level decisions is also important. This study examines the outcomes and characteristics of psychologists subject to formal notifications between 2004 and 2015. Data were extracted from archived notification files (N = 396) held by the New Zealand Psychologists Board alongside publically available decisions of the Health Practitioners Disciplinary Tribunal (N = 13). Annually, <2% of practising psychologists were subject of a notification. Outcomes varied by type of notification but the vast majority resulted in no further action either at initial triage or after further investigation. Notifications involving psychologist scope practitioners and those with overseas qualifications prior to New Zealand registration were significantly more likely to result in further investigation. All 13 prosecutions resulted in a finding of guilt. Further research is needed to explore risk factors and why female practitioners may be over-represented in cases of sexual boundary transgressions.

Examining a staging model for anorexia nervosa: empirical exploration of a four stage model of severity

BACKGROUND

An illness staging model for anorexia nervosa (AN) has received increasing attention, but assessing the merits of this concept is dependent on empirically examining a model in clinical samples. Building on preliminary findings regarding the reliability and validity of the Clinician Administered Staging Instrument for Anorexia Nervosa (CASIAN), the current study explores operationalising CASIAN severity scores into stages and assesses their relationship with other clinical features.

METHOD

In women with DSM-IV-R AN and sub-threshold AN (all met AN criteria using DSM 5), receiver operating curve (ROC) analysis (n = 67) assessed the relationship between the sensitivity and specificity of each stage of the CASIAN. Thereafter chi-square and post-hoc adjusted residual analysis provided a preliminary assessment of the validity of the stages comparing the relationship between stage and treatment intensity and AN sub-types, and explored movement between stages after six months (Time 3) in a larger cohort (n = 171).

RESULTS

The CASIAN significantly distinguished between milder stages of illness (Stage 1 and 2) versus more severe stages of illness (Stages 3 and 4), and approached statistical significance in distinguishing each of the four stages from one other. CASIAN Stages were significantly associated with treatment modality and primary diagnosis, and CASIAN Stage at Time 1 was significantly associated with Stage at 6 month follow-up.

CONCLUSIONS

Provisional support is provided for a staging model in AN. Larger studies with longer follow-up of cases are now needed to replicate and extend these findings and evaluate the overall utility of staging as well as optimal staging models.

Practitioner Health Issues Featuring Before New Zealand’s Health Practitioners Disciplinary Tribunal: An Analysis of Cases 2003-2014

Increasingly, the health and wellbeing of professionals is causing concern, particularly when it compromises the interests of those they serve. Often their health issues are reported when their conduct results in professional disciplinary action. In New Zealand, health practitioners who appeared before the Health Practitioners Disciplinary Tribunal for misconduct reported a range of physical and mental health conditions. This study of 288 decisions revealed the professions that reported diverse health issues, including categories of health issues, in published decisions between 2004 and 2014. The study also identified how frequently practitioners self-reported impairment or submitted health evidence from others of their physical and/or mental health status and/or their substance dependence. The study’s findings may be applied preventatively for the benefit of practitioners and the people they serve, thereby promoting the Health Practitioners Competence Assurance Act 2003 (NZ)’s emphasis on public safety.

Name Suppression Practices of New Zealand’s Health Practitioners Disciplinary Tribunal 2004-2014

Permanent name suppression decisions related to health practitioner disciplinary proceedings can result in debate across various interest groups, including practitioners, the public, the media and complainants themselves. However, there has been no analysis of name suppression patterns, principles and practices in New Zealand since the 2004 legislative reforms under the Health Practitioners Competence Assurance Act 2003 (NZ) provided for the combined regulation of 21 health professions and established the Health Practitioners Disciplinary Tribunal (HPDT) to hear and determine charges relating to those professions. This article reviews health practitioner name suppression debates within New Zealand in light of an exploratory descriptive analysis that was undertaken of 288 published decisions of the HPDT from 2004 to 2014. The study revealed that just under one-half of all cases involved a permanent name suppression application; amongst these, just over one-third were approved. Grounds cited for approving or declining name suppression varied and generally reflected established case law regarding naming principles and the Act’s intent. While the public interest dominated as the most frequently cited reason to decline name suppression, the most frequent justification for granting name suppression was the health and wellbeing of various individuals. The findings have relevance for understanding current trends in name suppression, and whether there are changing practices or differences adopted between health practitioner groups.

Evaluating quality of life outcomes following joint replacement: psychometric evaluation of a short form of the WHOQOL-Bref

PURPOSE

Reducing participant burden is important in health research and clinical assessment. We examined the psychometric properties of the EUROHIS-QOL 8-item index, a short version of the 26-item World Health Organisation Quality of Life questionnaire (WHOQOL-Bref), in a sample of people receiving joint replacement surgery.

METHODS

Participants (n = 1008) completed the WHOQOL-Bref at either 6, 12, 24 or 60 months after hip or knee replacement. The factor structure, differential item functioning (DIF) and unidimensionality of the EUROHIS-QOL 8-item index were examined using exploratory and confirmatory factor analyses and Rasch analyses. Convergent validity was examined using correlations with the parent measure and other patient-reported outcome measures (Oxford scores, Western Ontario and McMaster Universities Osteoarthritis Index). Discriminant validity was assessed between groups reporting high versus low pain and function, and by joint replaced.

RESULTS

The measure demonstrated high internal consistency (α = 0.86), adequate convergent (r = 0.47-0.82, p < 0.001) and discriminant validity (p < 0.001). Factor and Rasch analyses supported a unidimensional structure. However, there were also indications of multidimensionality, with support for a two-factor model focusing on general health and function, and psychosocial aspects of QOL. There was minimal evidence of DIF, with just one item evaluating energy level showing DIF for age.

CONCLUSIONS

The EUROHIS-QOL 8-item index demonstrated adequate properties as a unidimensional scale and as a two-factor scale evaluating general health and function, and psychosocial aspects of quality of life. It is low on clinical and participant burden, showed minimal ceiling effects and showed good concurrent and discriminant validity.

Posttraumatic stress symptoms in police staff 12-18 months after the Canterbury earthquakes

Understanding posttraumatic stress disorder (PTSD) symptoms in police first-responders is an underdeveloped field. Using a cross-sectional survey, this study investigated demographic and occupational characteristics, coping resources and processes, along with first-responder roles and consequences 18 months following a disaster. Hierarchical linear regression (N = 576) showed that greater symptom levels were significantly positively associated with negative emotional coping (β = .31), a communications role (β = .08) and distress following exposure to resource losses (β = .14), grotesque scenes (β = .21), personal harm (β = .14), and concern for significant others (β = .17). Optimism alone was negatively associated (β = -.15), with the overall model being a modest fit (adjusted R(2) = .39). The findings highlight variables for further study in police.

Assessment of anorexia nervosa: an overview of universal issues and contextual challenges

AIM

Anorexia Nervosa (AN) is a complex and clinically challenging syndrome. Intended for specialist audiences, this narrative review aims to summarise the available literature related to assessment in the adult patient context, synthesising both research evidence and clinical consensus guidelines.

METHOD

We provide a review of the available literature on specialist assessment of AN focusing on common trajectories into assessment, obstacles accessing assessment, common presenting issues and barriers to the assessment process, the necessary scope of assessment, and tools and techniques. It describes the further step of synthesising assessment information in ways that can inform resultant care plans.

RESULTS

In addition to assessment of core behaviours and diagnostic skills, considerations for the expert assessor include the functions of primary care, systemic and personal barriers, knowledge of current assessment tools and research pertaining to comorbid pathology in AN, assessing severity of illness, role of family at assessment, as well as medical, nutritional and compulsory elements of assessment.

CONCLUSION

Comprehensive assessment of AN in the current healthcare context still remains largely the remit of the specialist ED clinician. Assessment should remain an on-going process, paying particular attention to available empirical evidence, thereby reducing the gap between research and practice.

What components of perfectionism predict drive for thinness?

Perfectionism and drive for thinness have both been described as predictors of eating disorders, but the relationship between these two constructs over time requires further investigation, as does the an understanding of what components of perfectionism are important in this relationship. Using a longitudinal design, a population of 175 young adults was followed up over a 4 month period. Structural equation modelling indicated a unidirectional relationship between evaluative concerns and drive for thinness, with evaluative concerns, measured at Time 1 predicting an increase in drive for thinness at Time 2. This finding has potential implications for understanding psychological symptoms that precede eating disorder symptoms, and may help build models about prevention and treatment. As a first study to prospectively examine this relationship, further research is needed to assess the generalisability of the findings, and to explore additional variables that may mediate the relationship between evaluative concerns and drive for thinness.

An examination of the factor structure of the Revised Illness Perception Questionnaire modified for adults with mild traumatic brain injury

OBJECTIVE

Factors influencing outcome after mild traumatic brain injury (MTBI) remain poorly understood. In other health conditions patient illness perceptions have been associated with outcome and have provided targets for effective interventions. These have not been systematically explored in MTBI and identifying reliable and valid measures of illness perceptions in MTBI is a first step before such concepts can be explored in clinical and research settings.

METHOD

This study investigated the factor structure and internal consistency reliability of the Illness Perceptions Questionnaire-Revised (IPQ-R) modified for MTBI in a sample of 147 adults recruited within 3 months of injury.

RESULTS

The results demonstrated a close replication of the original factor structure although there were notable exceptions likely to be specific to MTBI and potentially other acutely injured populations. Final scales showed good internal consistency although factors relating to causal attribution were less so.

CONCLUSION

The IPQ-R (MTBI) provides an acceptable measure of key components of injury perceptions after MTBI. Minor refinements appear required if this measure is to make a contribution to research and clinical practice in injury-based populations such as MTBI.

Health-care staff attitudes towards self-harm patients

OBJECTIVE

To examine attitudes towards self-harm patients and need for training about self-harm amongst health-care staff in Christchurch, New Zealand.

METHODS

Health-care staff from a general and a psychiatric hospital completed a questionnaire about their attitudes towards self-harm patients and their need for training about self-harm.

RESULTS

A total of 195 staff members completed the questionnaire (response rate 64.4%). Overall, health-care staff had both positive and negative attitudes towards self-harm patients. Staff believed that their contact was helpful to self-harm patients, that they were patient and understanding, and were optimistic about patients' outcomes. However, staff did not feel confident working with self-harm patients and believed that their training in this area was inadequate. Attitudes were not significantly associated with age, gender, or experience. However, more negative attitudes were significantly associated with higher levels of burnout (through high emotional exhaustion (p <0.0002) and low personal accomplishment (p <0.003)). Staff comments indicated that their greatest difficulties working with self-harm patients included repetitive self-harm, frustrating and difficult patient behaviour, communication difficulties, and time pressure. Staff suggestions for improvement included more training, provision of a handbook or guidelines, and greater flexibility with patient allocations.

CONCLUSIONS

Overall, health-care staff had positive attitudes towards self-harm patients, and a strong desire to help such patients. However, staff did not feel confident working with self-harm patients and had a strong desire for additional training in this area. Additional staff training in working with self-harm patients could have the potential to increase staff confidence and attitudes and enhance patient care.

Nutrition knowledge in young women with eating disorders in Australia and Singapore: a pilot study

OBJECTIVE

The aim of the present study was to compare nutrition knowledge levels in young women with and without an eating disorder (ED) in two countries.

METHOD

Women with a clinical ED (n = 55) and healthy control women (n = 99) in Australia and Singapore completed a Nutritional Knowledge Questionnaire, acculturation questionnaire and demographics survey. Nutrition knowledge was analysed in terms of clinical status, cultural group, acculturation, socioeconomic status and education level. results: Women with EDs had greater knowledge than controls, but the magnitude of the difference was small. Greater acculturation to Western culture was associated with greater knowledge.

CONCLUSIONS

The difference in nutrition knowledge between women with and without EDs is unlikely to be of clinical importance. The findings may reflect today's ubiquitous availability of nutrition information.

Burnout in hospital-based medical consultants in the New Zealand public health system

AIM

To assess the prevalence and severity of burnout in hospital-based medical consultants, and investigate associated demographic and professional characteristics.

METHOD

Utilising standardised measures of burnout (Maslach Burnout Inventory) and job satisfaction (Job Satisfaction Scale) this cross-sectional study recruited 267 consultants working in a large tertiary hospital in Christchurch, New Zealand.

RESULTS

Seventy-one percent of all eligible participants were recruited. The prevalence of burnout in each of the three dimensions was as follows: High Emotional Exhaustion=29.7%; High Depersonalisation=24.4%; Low Personal Accomplishment=31.2%. One in five consultants was assessed as having high overall burnout. Considered against the psychometric norms for medical workers, significantly more consultants than expected reported low Emotional Exhaustion (p<0.001) and low Depersonalisation (p<0.01). Working longer hours (p<0.01), lower job satisfaction (p<0.001), and shorter time in the current job (p<0.05) independently increased the risk of high Emotional Exhaustion. Working longer hours (p<0.05) and lower job satisfaction (p<.01) independently increased the risk of high Depersonalisation. Longer time in the same job increased the risk of low Personal Accomplishment (p<0.05). Longer hours worked (p<0.05), shorter vocational experience as a consultant (p<0.05), and lower job satisfaction (p<0.001) independently increased the risk of high overall burnout.

CONCLUSION

An unexpected proportion of consultants experience robust emotional well-being and healthy work engagement. However, for those experiencing high burnout, by severity or dimension, working long hours and low job satisfaction appear to be particularly contributory factors. Whilst remedial interventions should target the minority who experience significant burnout, studies using robust research designs are required to assess the meaningful clinical utility of these. The challenge remains to determine the optimal organisational practices to minimise burnout in this workforce.

Self-liking and self-competence: relationship to symptoms of anorexia nervosa

Self-esteem has been hypothesised to play a pivotal role in the development and treatment, and outcome of anorexia nervosa (AN). Though this relationship is typically investigated by considering self-esteem as a unitary construct, research suggests that this comprises of two related but distinct components of self-liking and self-competence. This study investigates the association between self-liking, self-competence, and symptomatology of AN through the course of a defined treatment episode in 77 women. Self-liking was significantly associated with laxative abuse. Self-competence was significantly associated with elevated ineffectiveness, perfectionism and interpersonal distrust. Although self-competence and eating disturbance severity significantly improved over the treatment episode, one in three participants reported a reduced self-like or self-competence. Changes in both self-competence and self-liking at the end of treatment was associated with changes in drive for thinness. Such findings have implications for treatment models concerned with improving self-esteem.

Restraint and eating concern in North European and East Asian women with and without eating disorders in Australia and Singapore

OBJECTIVE

To investigate eating disorder psychopathology, restraint and eating concern in young women with and without an eating disorder from two different ethnic groups in Australia and Singapore.

METHOD

The relationship of Eating Disorder Examination Questionnaire Global, Restraint and Eating Concern scores to cultural orientation and sociocultural factors was analysed in 154 women with and without an eating disorder. Participants were from the following backgrounds: North European Australian, East Asian Australian, Singaporean Chinese and North European expatriates in Singapore.

RESULTS

Women with eating disorders had similar psychopathology across the cultural groups. Among controls, Singaporean Chinese reported significantly greater overall eating disorder psychopathology than other cultural groups and greater restraint than North European Australians/expatriates. Eating concern was not associated with cultural group overall or acculturation to Western culture. Dissatisfaction with family functioning, socioeconomic status and education level were not significantly associated with any of the eating disorder measures.

CONCLUSION

In eating disorder psychopathology, the specific symptom of eating concern may transcend cultural influences.

Eating disorders across two cultures: does the expression of psychological control vary?

OBJECTIVE

Because both the expression of eating disorder (ED) symptoms and preferred psychological control styles may be affected by culture, the purpose of the present study was to examine whether the expression of psychological control in women with EDs varies across two cultures.

METHOD

North European Australian and Chinese Singaporean women (n = 117) with anorexia nervosa (n = 36), bulimia nervosa (n = 13) and eating disorders not otherwise specified (n = 3), and without an ED (n = 65) recruited in Australia and Singapore completed a multidimensional inventory assessing sense of control, domains of control, preferred means by which to gain control, and motivation for control.

RESULTS

Although the normative control profile for each culture differed slightly, control profiles among those with an ED were very similar across both cultures. However, the directionality and extent of specific aspects of control pathology associated with the presence of an ED differed across cultures. North European Australians with an ED were much more deviant from the cultural norm than their Chinese Singaporean ED counterparts in relation to overall sense of control, methods of gaining control, and control in the domain of body. Chinese Singaporean woman with an ED were much more deviant from the cultural norm than their North European Australian ED counterparts in the domain of control over impulses.

CONCLUSIONS

Having an ED powerfully distorts psychological control irrespective of culture. However the degree, directionality, and form of the displacement from normal control styles is also culture dependent. This has implications for treatments that attempt to redress or correct control issues in people with an ED in other cultures.

Nursing student attitudes to psychiatric nursing and psychiatric disorders in New Zealand

Attitudes towards mental illness and psychiatric nursing can have far-reaching consequences for patients and the perceived desirability of this as a future career choice. Attitudes can be both brought into training and affected by training experiences, although the direction of these associations is unclear. Using a cross-section design, this study investigates the associations between attitudes, demographic variables, mental illness exposure, and career aspirations in 164 nursing students. Year of training and area of intended practice independently predicted attitudes. These findings have important implications for nursing training. They demonstrate the need for specifically focusing training to target the students with the most negative attitudes.

An international collaborative database: its use in predicting length of stay for inpatient treatment of anorexia nervosa

OBJECTIVE

We describe the establishment of an Australasian multisite research database for inpatient treatment of anorexia nervosa (AN). Using this database, the second aim of this study is to investigate the extent to which length of stay (LOS) in participating facilities could be predicted at admission from patient, clinical, and site variables.

METHOD

Standardized demographic and clinical data were collated for 213 admission episodes involving 154 participants over a 20 month period from five Australian and one New Zealand specialist treatment centres.

RESULTS

While nine variables significantly predicted LOS on univariate analysis, linear regression determined that only body mass index, and having had 2-3 previous admissions made significant independent contributions to LOS.

DISCUSSION

Multisite databases offer a viable means by which to conduct clinical research, particularly in regard to low prevalence disorders such as AN. Their additional advantage is that of involving front-line practitioners recruiting participants more likely to be representative of cases seen across treatment centres. At just under a fifth of the total variance predicted by the best-fit model, LOS in hospital remains an aspect of AN treatment difficult to predict, and future studies need to explore variables other than the obvious demographic or clinical issues at admission. The clinical and planning implications are discussed.

"Knowing one's self" anorexic: implications for therapeutic practice

OBJECTIVE

Recent postmodernist studies of anorexia nervosa (AN) challenge current clinical understandings and therapies by illuminating not what AN is but how what it is known to be by clinicians helps construct the disorder and therapy for it. This study points to the equal if not greater importance of how patients know AN.

METHODS

Using a deconstructive approach, the discourses of a group of women diagnosed with severe AN were analyzed to reveal radically different versions of "knowing one's self" anorexic.

RESULTS

These versions of "self" have strategically different implications for, and meanings of, any therapeutic endeavour.

DISCUSSION

Postmodernist approaches point to the need for social reconstruction of lay and community understandings of AN. They also have implications at the level of individual therapy, and could be deployed with patients to establish individual but authentic bases for therapy.

Links between psychological sense of control and disturbed eating behavior in women with diabetes mellitus. Implications for predictors of metabolic control

PURPOSE

Eating disturbances and aspects of psychological control are both repeatedly cited as significant correlates of metabolic control in diabetes mellitus (DM), yet such findings are typically discussed in separate literatures and have been criticized for overreliance on outdated constructs of psychological control when more complex means of analysis are available.

METHODS

Utilizing a multidimensional control inventory, this study investigates the relationship between eating disturbance and psychological sense of control, and assesses the utility of these two constructs in predicting metabolic control in 96 women recruited from a specialist diabetes clinic.

RESULTS

Despite significantly overlapping relationships between these two predictor variables and metabolic control, it is control specific to the domain of interpersonal relationships, along with eating disturbance in the form of bulimia/food preoccupation, that independently predicts level of metabolic control.

CONCLUSIONS

These findings have implications for the current form and content of psychological interventions in the management of DM.

An analysis of consumer perspectives following contact with an eating-disorders service

OBJECTIVE

The views of consumers following contact with treatment for eating disorders represent an underresearched aspect of service provision. The aim of this paper is to examine patterns of consumer satisfaction following contact with a specialist eating-disorders service.

METHOD

Using both a structured and an open-ended questionnaire format, consumer perspectives were sought routinely through postal survey 3 months after the point of first contact. Responses were analysed from 120 patients who returned their questionnaires during the 2-year period ending in December 1998.

RESULTS

Although the structured response format indicated high rates of satisfaction, the open-ended format revealed five categories describing the perceived best and worst aspects following consultation with the service. The category of therapeutic alliance drew the majority of positive comments, while the most frequently cited worst aspect of consultation was the category of treatment type.

CONCLUSIONS

People with eating disorders form a unique group of mental health consumers to survey for satisfaction. While approval ratings prompted by both structured and open-ended questions were high, and centred around the theme of therapeutic alliance, the most frequent source of negative commentary was activities and structures considered essential by traditional treatment modalities. This provides important insights into the predicaments of people with eating disorders presenting for treatment, and the importance of developing satisfaction surveys to accommodate such predicaments and concerns.

Metabolic control and psychological sense of control in women with diabetes mellitus. Alternative considerations of the relationship

PURPOSE

Identifying psychological strategies to buffer the adverse outcomes in people with diabetes mellitus (DM) remains a priority for many health professionals. While 'locus of control' (LOC) has been repeatedly investigated to this end, research findings are contradictory. The development of more complex appraisals of psychological control, and the utilization of control inventories deriving from such analyses, presents a way forward from such contradictions.

METHODS

Employing such a measure, this study examines the relationship between metabolic control and psychological sense of control in 96 women with DM.

RESULTS

Optimal metabolic control is significantly associated with overall sense of control, while poor metabolic control was significantly associated with experiences of loss of psychological control and feelings of inadequacy. Furthermore, poor metabolic control was significantly associated with reduced control in the specific domains of interpersonal relationships and bodily functions.

CONCLUSIONS

Multidimensional control inventories enable a more complex appraisal of the relationship between metabolic control and psychological control, and in doing so, provide a way forward from problems arising from reliance on LOC constructs. Interventions for DM management relying on aspects of psychological control need to target domains beyond traditional issues of self and bodily functions.

Eating disorder in a transgendered patient: a case report

This paper reports the case of a 25-year-old biological male transgendered patient referred to a specialist eating disorder service, and presenting with persistent purging, subjective binging, and restricting. She articulated a close link between transgender issues and the development of eating disorder symptoms. By virtue of its emphasis on estrangement from body, biological gender, and expected social role, transgenderism may constitute a risk factor for developing an eating disorder in certain men.

Referrals to a comprehensive eating disorders service

AIM

The purpose of this study was to review referral patterns and management decisions of patients consecutively referred to a comprehensive eating disorders service over a 12 month period.

METHOD

Data was collected from 211 patients referred to the eating disorders service in 1993 as part of an ongoing quality assurance programme undertaken by the service.

RESULTS

Seventy seven percent of referrals were received directly from general practitioners and 84% patients presented with a clinically significant eating disorder subsequently managed on an outpatient basis. Additional psychiatric diagnoses were present in 58% of all cases. Inpatient admission was a rare but prolonged event.

CONCLUSION

Although referral rates have escalated over recent years, most patients have at least one clinically significant psychiatric disorder requiring active intervention. Additional psychopathology over and above an eating disorder is common, and on occasions this takes treatment precedence. There are numerous treatment, teaching, and efficiency advantages in providing speciality eating disorder services, although it would seem difficult to justify multiple inpatient sites within any regional health authority.